As Global Abortion Levels Decline, Unsafe Abortions Rise

Kate Johnson

January 20, 2012

January 20, 2012 — A previously declining global abortion rate is now flatlining, yet the number of unsafe abortions is on the rise, according to the latest figures published online January 19 in the Lancet.

"Our findings show that the substantial decline in the abortion rate observed between 1995 and 2003 has tapered off, and the proportion of abortions that are unsafe has increased since 1995, such that nearly half of all abortions worldwide were unsafe in 2008," write the lead author of the study, Gilda Sedgh, ScD, from the Guttmacher Institute in New York City, and colleagues.

"A growing proportion of abortions are taking place in developing countries, where they are generally illegal and unsafe," Dr. Sedgh said at a press conference hosted by the journal in London in the United Kingdom.

"The findings lead naturally to the recommendation that greater investment in family planning is needed to break this stall and to reduce the unintended pregnancy rates and the abortions that they lead to," she told reporters.

The study, undertaken jointly by the Guttmacher Institute and the World Health Organization (WHO), looked at global trends in both safe and unsafe abortions in the years 1995, 2003, and 2008, and examined the association of these trends with legal status of abortion around the world.

Abortion figures were estimated using official statistics, nationally representative surveys, published studies, and hospital records.

Unsafe abortion is defined by the WHO as "a procedure for termination of an unintended pregnancy done either by people lacking the necessary skills or in an environment that does not conform to minimum medical standards, or both."

However, acknowledging that "abortions done outside the bounds of law are likely to be unsafe even if they are done by people with medical training," the researchers also defined unsafe abortions as those "done in countries with highly restrictive abortion laws, and those that do not meet legal requirements in countries with less restrictive laws."

The study found that although the global abortion rate (defined as the number of abortions per woman aged 15 - 44 years) declined between 1995 and 2003, from 35 to 29, per 1000 women, the rate leveled off between 2003 and 2008.

In absolute numbers, there were an estimated 43.8 million abortions worldwide in 2008 compared with 41.6 million in 2003 and 45.6 million in 1995, the researchers report.

About 78% of the world's abortions occurred in developing countries in 1995, rising to 86% in 2008.

The estimated worldwide percentage of pregnancies ending in abortion was 22% in 1995, 20% in 2003, and 21% in 2008, but although this rate declined in the developed world, from 36% in 1995 to 26% in 2008, it remained stable at 19% to 20% in the developing world.

"Since 2003, the number of abortions fell by 0.6 million in the developed world, but increased by 2.8 million in developing countries," the authors write.

"Worldwide, 49% of abortions were unsafe in 2008, up from 44% in 1995," they note. Although nearly 97% of abortions were unsafe in Africa, unsafe abortions were "too few to count" in North America, said Dr. Sedgh.

"When we put our findings together with [United Nations (UN)] estimates of contraceptive prevalence, we were able to see a correspondence," said Dr. Sedgh. Specifically, with a UN-documented plateau in contraceptive uptake, there was a corresponding plateau in the abortion decline, she said.

"Some 215 million women in developing countries have an unmet need for contraception; that is, they are sexually active, they want to avoid getting pregnant, but they're not using a modern method of contraception," she said.

There was also a correlation between abortion rates and legal restrictions, with lower abortion rates seen in regions with liberal abortion laws (P < .05), she said.

"The evidence suggests that restrictive abortion laws are not having the impact they were meant to have," she noted, adding that "in developing countries, illness and death from unsafe abortions have declined where abortion laws have been liberalized."

"Our findings point to a dire need to invest in efforts to reduce unintended pregnancies and unsafe abortions," write the authors.

"Regardless of the legal status of abortion in any setting, the provision of postabortion care is not illegal, and postabortion care should be expanded to help us minimize the consequences of unsafe abortions where unsafe abortions are prevalent," Dr. Sedgh added.

In an accompanying commentary Beverly Winikoff, MD, and Wendy Sheldon, MPH, MSW, from Gynuity Health Projects in New York City, write that the study "shows that it is precisely where abortion is illegal that it must become safer."

"Almost the entire global burden of deaths due to abortion occurs in Africa, Asia, and Latin America. Somehow, we typically act as if this were neither surprising nor troubling. But there are no regional biological differences in women that could account for this discrepancy; there is no procedure to prevent death from abortion that is unknown to practitioners where the toll is high; and there are no costly technologies needed to avoid these deaths. If a lack exists, it is a lack of caring: a willingness to sacrifice lives to an ideological moral high ground, to social acceptability, or to the maintenance of a political comfort zone," they write.

The answer to these "deeply disturbing" abortion figures is in "more liberal abortion laws," said Richard Horton, MD, editor of the Lancet, at the press conference. Yet just the mention of the word abortion "leads to a phenomenal and visceral reaction against even discussing the issue," he said. "Even under an Obama administration it is not possible to have an open discussion about abortion in international agencies and commissions, and this stigmatization, this censorship around the issue of abortion, is what is causing this enormous distortion in women's health today."

Reached for comment on the study, Rachelle Seguin, RN, a nurse at the Jewish General Hospital in Montreal, Quebec, Canada, and a medical team leader and reproductive health specialist with Doctors Without Borders (Médecins Sans Frontières), said she is not surprised by the findings.

From her work in regions where abortion is illegal (Central African Republic, Philippines, and Haiti), she learned that "the risk women take to abort is horrifying."

"No matter the laws, there are always ways and means to abort, they just are generally unsafe," she told Medscape Medical News. "You can find medication sold on the streets, which women will buy, but perhaps they can't afford the entire dosage to abort. [This] can cause them to only partially abort, and cause retained tissue in the uterus, and this can result in hemorrhaging. At one point we could see over 30 women per week with this scenario," she said. "We had the means to do curettage, which removes the retained tissue, and in short will stop the hemorrhaging, and we would continue with the postabortion care."

Ms. Seguin agreed that more liberal abortion laws may help, but she said general societal attitudes also have to change. She has seen giant boxes of contraceptives collecting dust and reaching their expiry dates in officials' offices because "for some, abortion and contraceptives go hand in hand: both are wrong."

Public education is also a challenge, she said, as many men assume infidelity if their wives use contraception, and many women are misinformed about the risks of contraception to future fertility, among other things.

In addition, "anywhere where there is conflict, war, if the population is not fixed but running from violence, how will they continue to have access?"

"I would like to think that what this research shows will help encourage governments that if their goal is to have less abortions, then tightening the law defeats the purpose," she said.

The study was supported by the UK Department of International Development, the Dutch Ministry of Foreign Affairs, and the John D. and Catherine T. MacArthur Foundation. The authors, commentators, Dr. Horton, and Ms. Seguin have disclosed no relevant financial relationships.

Lancet. Published online January 19, 2012. Full text, Editorial extract

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